Anatomic double-bundle ACL reconstruction using a bone–patellar tendon–bone autograft: a technical note

This article describes an original arthroscopic double-bundle anterior cruciate ligament (ACL) reconstruction technique using a bone–patellar tendon–bone autograft. A rectangular patellar bone block, with a double strand patellar tendon, and a double tibial bone block is harvested. The femoral anteromedial tunnel is made using an all-inside technique by the anteromedial portal. The femoral posterolateral (PL) tunnel is created with an outside-in technique, with a 30° divergence between both tunnels. A single tibial tunnel is drilled, the graft is then passed through the tibial tunnel, and the bundles are separately tensioned and fixed with three bioabsorbable interference screws. The femoral AM bone block is fixed by the anteromedial portal, the tibial bone block is then fixed in an oblique manner in order to mimic the ACL orientation with the knee at 30° of flexion. The femoral PL bone block is fixed at the end with the knee in full extension.     

Bone-patellar tendon-bone autograft versus hamstring autograft anterior cruciate ligament reconstruction in the young athlete: a retrospective matched analysis with 2–10?year follow-up

Purpose

The aim of this study was to examine clinical and patient-reported outcomes as well as return to sport in athletes younger than 25 following ACL reconstruction with either bone-patellar tendon-bone (BTB) or hamstring (HS) autografts using a matched-pairs case–control experimental design.

Methods

Twenty-three matched pairs were obtained based on gender (57% women), age (18?±?3?years BTB vs. 18?±?3 HS), and length of follow-up (5?±?2?years BTB vs. 4?±?2 HS). Patients reported participating in very strenuous (soccer, basketball, etc.) or strenuous (skiing, tennis, etc.) sporting activity 4–7 times/week prior to their knee injury. Patient-reported outcomes included return to play data, the IKDC, SAS, ADLS, and SF-36 forms. Clinical outcomes included knee range of motion, laxity, and hop/jump testing.

Results

The majority of patients in both groups were able to participate in very strenuous or strenuous sporting activity 4–7 times per week following surgery [17 (74%) BTB vs. 16 (70%) HS]. However, only 13 (57%) of the BTB subjects and 10 (44%) of the HS patients were able to return to pre-injury activity levels (P?=?n.s.). HS patients showed higher ADLS (P?P?P?P?Conclusions Hamstring and bone-patellar tendon-bone autografts allow approximately 70% of young athletes to return to some degree of strenuous or very strenuous sporting activity, while only approximately half of patients were able to return to their pre-injury sporting activity level. Hamstring grafts lead to better preservation of extension, higher patient-reported outcome scores, and less radiographic evidence of osteoarthritis.

Level of evidence

Therapeutic (case–control study) Level III.     

Medial hamstring muscle activation patterns are affected 1–6 years after ACL reconstruction using hamstring autograft

Purpose

Although changes in hamstring muscle morphology after anterior cruciate ligament reconstruction (ACLR) using a semitendinosus autograft hamstrings-gracilis (HG) of the ipsilateral limb are recognized, alterations in muscle activation patterns have not been extensively studied. The purpose of this controlled laboratory trial was therefore to monitor muscle activation levels of the medial (MH) and lateral (LH) hamstring muscles in athletes who had undergone ACLR using a HG autograft and to contrast these to activation levels demonstrated by healthy controls.

Methods

Surface electromyography (EMG) was sampled from bilateral hamstring muscles of 18 athletes 1–6 years after ACLR and 18 matched controls (CTRL) during the performance of two dissimilar exercises, both involving eccentric knee flexor activity. Peak normalized muscle activation levels were identified for MH and LH of both limbs during the performance of the Nordic Hamstring (NH) exercise and TRX^® hamstring curl (TRX) exercise.

Results

A statistically significant limb by exercise interaction was found for peak activation levels of LH, due to significant interlimb differences in activation during the performance of the TRX exercise compared to more symmetrical activation during the NH (p < 0.001). A three-way interaction was found for peak activation levels of MH, due to group differences in peak muscle activation between limbs and exercise type (p = 0.025). Whereas CTRL group participants consistently favoured one limb over the other during the performance of both exercises, ACLR participants demonstrated dissimilar peak MH activation patterns between limbs during the performance of the NH exercise compared to the TRX.

Conclusions

In light of these results and considering the surgical procedure, patients who undergo ACLR using a HG autograft from the ipsilateral limb may benefit from post-operative rehabilitation that involves muscle activation and strengthening specifically targeting the MH component.     

Does autograft choice determine intermediate-term outcome of ACL reconstruction?

Purpose  

Many clinical studies and systematic reviews have compared the short-term (2 years) outcomes of ACL reconstruction with hamstring and patellar tendon autograft. Few differences have been observed, with the exception of increased kneeling pain with patellar tendon grafts. The goal of this systematic review is to determine whether there are differences in clinical, patient-reported, or radiographic outcomes based on graft choice at a minimum of 5 years after ACL reconstruction.     

Anterior cruciate ligament reconstruction in patients over 40 years using hamstring autograft

Anterior cruciate ligament (ACL) reconstruction is becoming increasingly popular in active middle-aged patients with symptomatic instability. The purpose of this study was to retrospectively evaluate the results of ACL reconstruction in patients over the age of 40. Twenty-one patients with a median age of 44 (range 40–56) who had arthroscopically assisted reconstruction using four-stranded hamstring autograft were reviewed. RCI titanium interference screw fixation was used in the tibia, and Endobutton CL fixation in the femur. The clinical results were assessed at a mean follow-up of 2 years. The median value for the Lysholm knee score was 92 (range 74–100), and the median value for the International Knee Documentation Committee score was 83 (range 53–97). For the Tegner activity scale, the median value was 6 (range 4–8) at follow-up. The median side-to-side difference using the KT-1000 arthrometer was 2 mm (range 0–3.5 mm). Hamstring ACL reconstruction in appropriately selected middle-aged patients can yield successful and satisfactory results.     

Bone anchors or interference screws? A biomechanical evaluation for autograft ankle stabilization

BACKGROUND: Autograft stabilization uses free semitendinosus tendon grafts to anatomically reconstruct the anterior talofibular ligament. Study aims were to evaluate the biomechanical properties of Mitek GII anchors compared with the Arthrex Bio-Tenodesis Screw for free tendon reconstruction of the anterior talofibular ligament. NULL HYPOTHESIS: There are no differences in load to failure and percentage specimen elongation at failure between the 2 methods. STUDY DESIGN: Controlled laboratory study using porcine models. METHODS: Sixty porcine tendon constructs were failure tested. Re-creating the pull of the anterior talofibular ligament, loads were applied at 70 degrees to the bones. Thirty-six tendons were fixed to porcine tali and tested using a single pull to failure; 10 were secured with anchors and No. 2 Ethibond, 10 with anchors and FiberWire, 10 with screws and Fiberwire, and 6 with partially gripped screws. Cyclic preloading was conducted on 6 tendons fixed by anchors and on 6 tendons fixed by screws before failure testing. Two groups of 6 components fixed to the fibula were also tested. RESULTS: The talus single-pull anchor group produced a mean load of 114 N and elongation of 37% at failure. The talus single-pull screw group produced a mean load of 227 N and elongation of 22% at failure (P <.05). Cyclic preloading at 65% failure load before failure testing produced increases in load and decreases in elongation at failure. Partially gripped screws produced a load of 133 N and elongation of 30% at failure. The fibula model produced significant increases in load to failure for both. The human anterior talofibular ligament has loads of 139 N at failure with instability occurring at 20% elongation. CONCLUSIONS: Interference screw fixation produced significantly greater failure strength and less elongation at failure than bone anchors. Clinical Relevance: The improved biomechanics of interference screws suggests that these may be more suited to in vivo reconstruction of the anterior talofibular ligament than are bone anchors.     

Anterior cruciate ligament reconstruction autograft choice: bone-tendon-bone versus hamstring: does it really matter? A systematic review

Anterior cruciate ligament graft choice is controversial, with no evidence-based consensus available to guide decision making. The study design was evidence-based medicine systematic review of randomized controlled trials evaluating patellar tendon versus hamstring tendon autografts. A literature review identified 9 randomized controlled trials comparing patellar tendon and hamstring tendon autografts. An evidence-based systematic review was performed. Objective and subjective outcomes of interest included surgical technique, rehabilitation, instrumented laxity, isokinetic strength, patellofemoral pain, return to preinjury activity, and Tegner, Lysholm, Cincinnati, and International Knee Documentation Committee-1991 scores. Additional surgery, graft failure, and complications were reviewed. Slight increased laxity on arthrometer testing was seen in the hamstring population in 3 of 7 studies. Pain with kneeling was greater for the patellar tendon population in 4 of 4 studies. Only 1 of 9 studies showed increased anterior knee pain in the patellar tendon group. Frequency of additional surgery seemed to be related to the fixation method and not graft type. No study reported a significant difference in graft failure between patellar tendon and hamstring tendon autografts. Objective differences (range of motion, isokinetic strength, arthrometer testing) were not detected between groups in the majority of studies, suggesting that their sensitivity to detect clinical outcomes may be limited. Increased kneeling pain in the patellar tendon group was seen consistently in the studies evaluated. Subjective differences in anterior knee pain or return-to-activity level were not consistently observed in these studies. With numbers available, failure rates were not significantly different between groups. These findings suggest that graft type may not be the primary determinant for successful outcomes after anterior cruciate ligament surgery.     

ACL reconstruction using 5- or 6-strand hamstring autograft provides graft’s diameter bigger than 8 mm

Purpose

The objective of this study was to measure the diameters of 5- and 6-strand hamstring autografts and to evaluate the predictability of their thickness by other body size indices.

Methods

Data were collected from 122 skeletally mature adult patients, who had undergone arthroscopic anterior cruciate ligament reconstruction using only 5- or 6-strand hamstring autografts. The diameters of tibial and femoral ends of the grafts were measured with the precision of 0.5 mm. Multiple linear regression was performed to determine the relationship between autograft’s thickness and body size indices.

Results

The diameter of the femoral end of the 5-strand graft in male/female patients on average was 8.9/8.3 mm, while the femoral end of the 6-strand graft—9.3/8.5 mm (respectively). In 98.4% of the cases, 5- or 6-strand hamstring autografts were significantly thicker than 8 mm. In 5-strand group, a significant positive correlation was detected between the diameter of autograft’s femoral end and patient’s height (r = 0.55; p < 0.001), weight (r = 0.60; p < 0.001) and BMI (r = 0.43; p < 0.01). The 6-strand group had statistically significant correlations between the femoral end of the graft and height (r = 0.53; p < 0.001), and femoral end of the graft and weight (r = 0.50; p < 0.001).

Conclusions

Hamstring autografts were significantly thicker than 8 mm. Taller and heavier persons tended to have greater diameters of hamstring autografts; however, to better predict the diameter of autograft, body composition should be studied in relation to autograft’s size. Preparation of 5- or 6-strand graft (using all the length of hamstring tendons) provides almost 100% of probability to obtain graft’s diameter bigger than 8 mm.

Level of evidence

Level III.

     

ACR–ABS–ACNM–ASTRO–SIR–SNMMI practice parameter for selective internal radiation therapy or radioembolization for treatment of liver malignancies

PurposeThe American College of Radiology (ACR), American Brachytherapy Society (ABS), American College of Nuclear Medicine (ACNM), American Society for Radiation Oncology (ASTRO), Society of Interventional Radiology (SIR), and Society of Nuclear Medicine and Molecular Imaging (SNMMI) have jointly developed a practice parameter on selective internal radiation therapy (SIRT) or radioembolization for treatment of liver malignancies. Radioembolization is the embolization of the hepatic arterial supply of hepatic primary tumors or metastases with a microsphere yttrium-90 brachytherapy device.Materials and MethodsThe ACR -ABS -ACNM -ASTRO -SIR -SNMMI practice parameter for SIRT or radioembolization for treatment of liver malignancies was revised in accordance with the process described on the ACR website (https://www.acr.org/ClinicalResources/Practice-Parameters-and-Technical-Standards) by the Committee on Practice Parameters—Interventional and Cardiovascular Radiology of the ACR Commission on Interventional and Cardiovascular, Committee on Practice Parameters and Technical Standards—Nuclear Medicine and Molecular Imaging of the ACR Commission on Nuclear Medicine and Molecular Imaging and the Committee on Practice Parameters—Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with ABS, ACNM, ASTRO, SIR, and SNMMI.ResultsThis practice parameter is developed to serve as a tool in the appropriate application of radioembolization in the care of patients with conditions where indicated. It addresses clinical implementation of radioembolization including personnel qualifications, quality assurance standards, indications, and suggested documentation.ConclusionsThis practice parameter is a tool to guide clinical use of radioembolization. It focuses on the best practices and principles to consider when using radioemboliozation effectively. The clinical benefit and medical necessity of the treatment should be tailored to each individual patient.     

Mass spectrometric differentiation of the isomers of mono-methoxyethylamphetamines and mono-methoxydimethylamphetamines by GC–EI–MS–MS

Mass spectrometric differentiation of the six isomers of mono-methoxyethylamphetamines (MeO-EAs) and mono-methoxydimethylamphetamines (MeO-DMAs) by gas chromatography–electron ionization–tandem mass spectrometry (GC–EI–MS–MS) was investigated. Based on their EI-mass spectra, the fragment ions at m/z 121 and 72 were selected as precursor ions for their regioisomeric and structurally isomeric differentiation, respectively. Collision-induced dissociation provides intensity differences in product ions among the isomers, enabling mass spectrometric differentiation of the isomers. Furthermore, high reproducibility of the product ion spectra at the optimized collision energy was confirmed, demonstrating the reliability of the method. To our knowledge, this is the first report on mass spectrometric differentiation of the six isomers of MeO-EAs and MeO-DMAs by GC–EI–MS–MS. Isomeric differentiation by GC–EI–MS–MS has a high potential to discriminate isomers of newly encountered designer drugs, making GC–MS–MS a powerful tool in the forensic toxicology field.     

Long-term results of arthroscopically assisted anatomical single-bundle anterior cruciate ligament reconstruction using patellar tendon autograft: are there any predictors for the development of osteoarthritis?

Purpose

The primary purpose of our study was to analyse the long-term outcome of patients treated for anterior cruciate ligament (ACL) tears by anatomical single-bundle ACL reconstruction with patellar tendon autograft. The secondary purpose was to identify predictive factors for good outcome and occurrence of osteoarthritis.

Methods

Sixty-three patients (m:f = 54:9; mean age at surgery, 27 ± 7 years) treated by ACL reconstruction were evaluated with a mean follow-up of 16 ± 1 years using IKDC2000, the SF36, Lysholm and Tegner score, Knee Society score, visual analogue scale for pain and satisfaction and KOOS. The femoral tunnel position was evaluated according to Sommer. It was also assessed in percentage of the Blumensaat line and the tibial tunnel position in percentage of the total anterior–posterior plateau length. The extent of osteoarthritis was graded according to the Kellgren–Lawrence score.

Results

The total IKDC2000 was normal in 20 (32 %), nearly normal in 29 (46 %), abnormal in 12 (19 %) and severely abnormal in 3 (5 %) of patients. The mean total SF-36 was 89 ± 13, the Lysholm score 95 ± 12, the Knee Society score 191 ± 16 and the total KOOS 84 ± 19. The Tegner score decreased from pre-injury 7(4–10) to 6 (2–10) at follow-up. The Kellgren–Lawrence score was normal in 17 (27 %), suspected osteoarthritis in 25 (40 %), minimal osteoarthritis in 5 (8 %), moderate osteoarthritis in 9 (14 %) and severe osteoarthritis in 3 patients (5 %). The femoral tunnel was in zone A in 43 patients (68 %), in zone B in 16 (25 %) and in zone C in 4 patients (7 %). The femoral tunnel position in percentage of the Blumensaat line was 49 ± 3 (range, 44–57), and the tibial tunnel position in percentage of the total anterior–posterior plateau length was 32 ± 6 (range, 21–46). Patients with meniscal lesion at the time of ACL tear showed significantly less favourable outcomes than those without.

Conclusions

Patients treated by the proposed ACL reconstruction technique showed on average good to excellent long-term results. A meniscal lesion at the time of ACL tear was highly predictive for less favourable outcome.

Level of evidence

IV.